2011
RMM Programme: Some remaining challenges
02/10/11
There has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care (from about 1 per 1.200.000 population in 2008 to 1 per 250.000 population at the end of 2010; see following table). Although this is an essential requirement to cut maternal and neonatal deaths, the use of such services remains below what is needed to reduce maternal and neonatal deaths. However, lack of ambulance services remains a great challenge.
It is also important, as asked by the zonal health authorities, to increase the number of institutions carrying our CEOC with 6. At the end of 2015, the area will then have one institution per 160.000 people. This is about the target the Ethiopian Government has set during the next five years.
Our study shows that of the 64 major health institutions in Gamu Gofa Zone, only a few were carrying out Basic Emergency Obstetric care. We therefore think it is essential to include these institutions in our future programme, and thereby improving the access of the population to such services, and to improve referrals to institutions with CEOC.
Although staff retention has been good, it is important to sustain staffing the institutions. Of particular importance is to improve the skills so more operations can be done at these remote institutions. We therefore aim to support a masters programme for health officers at Arba Minch University.
The main causes of maternal deaths, as documented by our review of health institutions and by our population-based registries, show that bleedings, infections and pre-eclampsia represent the main cases of death. As most of the births still occur at home and attended by traditional birth attendants or family members, we need to find ways to reduce bleedings and infections during home deliveries.
Several of the institutions carrying out CEOC do not functioning optimally because they lack adequate blood transfusion services. To reduce maternal deaths from bleeding and from uterine ruptures we need to improve the blood transfusion services at these institutions.
It is also important, as asked by the zonal health authorities, to increase the number of institutions carrying our CEOC with 6. At the end of 2015, the area will then have one institution per 160.000 people. This is about the target the Ethiopian Government has set during the next five years.
Our study shows that of the 64 major health institutions in Gamu Gofa Zone, only a few were carrying out Basic Emergency Obstetric care. We therefore think it is essential to include these institutions in our future programme, and thereby improving the access of the population to such services, and to improve referrals to institutions with CEOC.
Although staff retention has been good, it is important to sustain staffing the institutions. Of particular importance is to improve the skills so more operations can be done at these remote institutions. We therefore aim to support a masters programme for health officers at Arba Minch University.
The main causes of maternal deaths, as documented by our review of health institutions and by our population-based registries, show that bleedings, infections and pre-eclampsia represent the main cases of death. As most of the births still occur at home and attended by traditional birth attendants or family members, we need to find ways to reduce bleedings and infections during home deliveries.
Several of the institutions carrying out CEOC do not functioning optimally because they lack adequate blood transfusion services. To reduce maternal deaths from bleeding and from uterine ruptures we need to improve the blood transfusion services at these institutions.
Lessons learnt from Phase I of the RMM project
29/09/11
From our experience, it is encouraging that maternal mortality rates decline in Ethiopia. This may reflect an increased coverage of essential obstetric services that contributes to a decline in maternal mortality rates. In our catchment are, the number of Caesarean sections has doubled since its start in 2008, and has already averted many maternal deaths and deaths of newborn babies.
However, preliminary results from the birth registration from Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality Ratio (MMR) might be as high as 545 per 100.000 births. Since we started the RMM project, stillbirths have recently received increasing attention, and these figures compare well with our birth registry reports, which show the stillbirth rate is about 50% of the neonatal mortality rate. This is the first result of such registration in Ethiopia, and provides the project with a unique opportunity to develop and monitor progress in reducing maternal deaths.
The RMM First Phase (2008 – 2011) highlighted the following strategy:
Training programme
A major problem in rural Ethiopia is the lack of trained health personnel. Our project represents the first attempt train non-clinician physicians on a larger scale. We are encouraged by the new policy of the Ethiopian Government to upgrade 800 health centres to rural hospitals. Our project has enabled three hospitals (Gidole, Chencha and Saula) and four health centres (Kemba, Konso, Basketto and Melo) to routinely provide their populations with CEOC. We currently work to enable the health centres in Turmi, and Kucha to routinely provide CEOC. We continuously review the operations done at the institutions, and the results are encouraging, and comparable to work done in Mozambique and Tanzania.
The work of the RMM project has also resulted in the planning for two new hospitals in south Ethiopia: in Kemba and in Konso. We recently donated hospital beds and some medical equipment to the new hospital in Kemba.
Equipment
All participating institutions have received basic equipment to carry our comprehensive emergency obstetric operations.
Supervision
One lesson from our work is the need to follow up and support the health officers, anaesthesia nurses and midwives at the peripheral institutions. Thus, we supervise and support our collaborating institutions. We also encourage the institutions to collaborate with one another, and thus form networks that strengthen their work. For example, staff from Saula Hospital take part in our visits to Melo and Basketto. Arba Minch Hospital has developed good working relations with the institutions in Kemba, Chencha, Gidole and Konso.
Health extension workers (HEW)
Training HEW continues as planned. The training unit in Gidole is completed, and all HEW completed their training at Gidole Hospital Similar training has been done at Jinka, Arba Minch, Chencha and Saula Hospitals.
Building works
We built a training centre in Gidole, and we expanded or built Maternity Waiting Areas in Kemba, Chencha, Jinka and in Saula.
The new women’s ward at Arba Minch Hospital is complete. Thus the hospital has new delivery ward, gynaecological department, outpatient department for women, a new fistula unit, and a new Mother and Child OPD. The hospital has two new operation theatres, and a new sterilisation unit have also been completed. Although this construction is not a part of the RMM project, it strengthens the Arba Minch Hospital as a training and teaching hospital.
Operational research
As in many other African countries, Ethiopia lacks information on why and how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries.
Most encouraging: there has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care, from 1 per 1.000.000 population in 2008 to 1 per 250.000 population at the end of 2010. This is an essential requirement to reduce maternal and neonatal deaths.
Health extension workers in each local community (kebele) register all births and delivery outcomes. With birth registries at institutions, this will provide the regional and national health authorities with essential information for planning and improving the health services. It will also enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two Masters (Meseret Girma and Tadesse Data) completed their training in 2011, and one PhD student (Yaliso Yaya) continues his research on community based institutional birth registries.
Our preliminary results from the birth registration from the three woredas in Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality ratio might be as high as 550 per 100.000 births. The mortality rates are lower for communities with better access to health institutions doing Comprehensive Emergency Obstetric Care. In remote areas, the maternal mortality rate is still very high (over 1500 / 100.000 births). More that 60% of the deaths are due to intrapartum bleeding. We therefore need to find methods to reduce bleeding after delivery when the birth takes place at homes.
The research done by Meseret Girma from Arba Minch University on 64 health centres and hospitals in Gamu Gofa Zone (population 1,7 million people) show that only 6% of the births takes place at health centres. More worrying, only 10 - 15% of deliveries with expected complications take place at health centres or hospitals.
However, preliminary results from the birth registration from Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality Ratio (MMR) might be as high as 545 per 100.000 births. Since we started the RMM project, stillbirths have recently received increasing attention, and these figures compare well with our birth registry reports, which show the stillbirth rate is about 50% of the neonatal mortality rate. This is the first result of such registration in Ethiopia, and provides the project with a unique opportunity to develop and monitor progress in reducing maternal deaths.
The RMM First Phase (2008 – 2011) highlighted the following strategy:
- Improve coverage of institutions with Comprehensive Emergency Obstetric Care (CEOC, that is institutions doing caesarean sections)
- Train essential staff. We focused on training health officers, nurse anaesthetists, scrub nurses and midwives
- Equip the participating institutions with essential equipment to carry out CEOC
- Supervise staff at the participating institutions doing CEOC
- Improving the works of health extension workers so they refer delivery cases to institutions.
Training programme
A major problem in rural Ethiopia is the lack of trained health personnel. Our project represents the first attempt train non-clinician physicians on a larger scale. We are encouraged by the new policy of the Ethiopian Government to upgrade 800 health centres to rural hospitals. Our project has enabled three hospitals (Gidole, Chencha and Saula) and four health centres (Kemba, Konso, Basketto and Melo) to routinely provide their populations with CEOC. We currently work to enable the health centres in Turmi, and Kucha to routinely provide CEOC. We continuously review the operations done at the institutions, and the results are encouraging, and comparable to work done in Mozambique and Tanzania.
The work of the RMM project has also resulted in the planning for two new hospitals in south Ethiopia: in Kemba and in Konso. We recently donated hospital beds and some medical equipment to the new hospital in Kemba.
Equipment
All participating institutions have received basic equipment to carry our comprehensive emergency obstetric operations.
Supervision
One lesson from our work is the need to follow up and support the health officers, anaesthesia nurses and midwives at the peripheral institutions. Thus, we supervise and support our collaborating institutions. We also encourage the institutions to collaborate with one another, and thus form networks that strengthen their work. For example, staff from Saula Hospital take part in our visits to Melo and Basketto. Arba Minch Hospital has developed good working relations with the institutions in Kemba, Chencha, Gidole and Konso.
Health extension workers (HEW)
Training HEW continues as planned. The training unit in Gidole is completed, and all HEW completed their training at Gidole Hospital Similar training has been done at Jinka, Arba Minch, Chencha and Saula Hospitals.
Building works
We built a training centre in Gidole, and we expanded or built Maternity Waiting Areas in Kemba, Chencha, Jinka and in Saula.
The new women’s ward at Arba Minch Hospital is complete. Thus the hospital has new delivery ward, gynaecological department, outpatient department for women, a new fistula unit, and a new Mother and Child OPD. The hospital has two new operation theatres, and a new sterilisation unit have also been completed. Although this construction is not a part of the RMM project, it strengthens the Arba Minch Hospital as a training and teaching hospital.
Operational research
As in many other African countries, Ethiopia lacks information on why and how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries.
Most encouraging: there has been a substantially improvement in the number of institutions providing comprehensive emergency obstetric care, from 1 per 1.000.000 population in 2008 to 1 per 250.000 population at the end of 2010. This is an essential requirement to reduce maternal and neonatal deaths.
Health extension workers in each local community (kebele) register all births and delivery outcomes. With birth registries at institutions, this will provide the regional and national health authorities with essential information for planning and improving the health services. It will also enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two Masters (Meseret Girma and Tadesse Data) completed their training in 2011, and one PhD student (Yaliso Yaya) continues his research on community based institutional birth registries.
Our preliminary results from the birth registration from the three woredas in Dirashe, Bonke and Arba Minch Zuria shows the Maternal Mortality ratio might be as high as 550 per 100.000 births. The mortality rates are lower for communities with better access to health institutions doing Comprehensive Emergency Obstetric Care. In remote areas, the maternal mortality rate is still very high (over 1500 / 100.000 births). More that 60% of the deaths are due to intrapartum bleeding. We therefore need to find methods to reduce bleeding after delivery when the birth takes place at homes.
The research done by Meseret Girma from Arba Minch University on 64 health centres and hospitals in Gamu Gofa Zone (population 1,7 million people) show that only 6% of the births takes place at health centres. More worrying, only 10 - 15% of deliveries with expected complications take place at health centres or hospitals.
